S 0534 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
RUINIG ' 'CA L 111' 111rr NO.
CITY OF CUPERTINO PLUMBING.
MECLECHAICA
BUILDING DIVISION. APPLICATION/PERMIT III11DINGIR( IRCIIDENUIPICATI(N 0534
BUILDING ADDRESS'. - SANI1'ARV NO. AI'1'LIC,AI'[ON SI111MI'I'IAI.DA'll
CA, LCT /d 8/-719-7
W�R'S NAME' ( CONTRACPORS NAME: LIC NOCGNTRf)I.M
'.
pEuC,q"-4rR'ffQMES S�vEt/ NIC
•ARCHITECT/ENGINEER: LICNO'. ADDRESS: ❑
/
CONTACT
C PHONE: BUILDING PERMIT INFO
✓� Q/.�¢(-572. ❑ Consultant Fees Pail by Applicant(initial) HI.DG rl;'.cf P�❑ ME H
LICENSED CONTRACTORS DECLARATION QTY, ELECTRIC PERMIT FEE JOU DESCRIPTION
I hereby alfran that I am licensed under provisions of Chapter 9 Uommeming
HOZ wilb Section 9l%Io)ofDivismT 3 afNc Business and PrOfesmic,Coda andnry licence is 'll 1 '
� in full force and effect. PIiRMIT ISSUANCE SFDWI ❑KITCHEN REMODEL
aUU Lmccnse Class Lic.p APPLIANCES-RIiMOENT1A1. AUDITION ❑PLUMBING RE-PIPE.
-Z W Dal, Contractor
ARCHITECTS DECLARATION PANHIS ❑h1UCT1-UNIT ❑NIGINF[ ATIO
F+yZ Iundemvnd my plans shall beusedaa publi,momds MODIFICATION
ZCw—
oz UPT020EAMPS ❑INTERIOR ❑CHIMNEY REPAIR
-Q
FE2f'W Licensed Professional 3111-1000AMIS IMI'ROVIiMIiN'1' �SWIh1MING POUTS
OWNER-BUILDER DECLARATION IT 1000AMCS ❑BATH RIiMOIIliDR1iPAIR DDEMOLITION
6 1 hereby affirm that 1 am exempt from the Contmanrs License Law far the OTHER
X�1U follOwingreaao0,(Section 7031.5.Business and Professions Coda:Any limy Or county SIGNS fLIiMRICAI.
W 3 LL N which Nm.a pa,d m con'nacl,alar,improve,demolklN or apair any savers
prior to its issuance.also requias the applicant for such Permit o file a signed statement SPECIAL CIRCUIT/MISC.
} that he is licenwd pursuant m the proviwnns of the Contractor'License law(Chapter 9
BMOC (commencingwilh Section 7(X10)of Division J of Ne Buslnessand Pndc,ionaCode)or TEMP.MIiI'IiN OR Iv)LE(NST. LT 1 ® �(1 R
0.6 e C that he is exempt Ncafrom and the basis for Nc alleged exemption.Any violation of N BI,UGIA l I {lfl�I0N
mSection 90]1.5 by any applicant for a Permit sahjxcts the applicant m a civil Penalty of POWER DEVICES TENANT, V ❑1'GOD SERVICE
not more than five hundred dollars 14500). IMPROVFaNjiN I(Jr
=C1]1.as Owner of the pmpcny.or my employees with wages as Neirsulc mmpcnntion, SWIMMING POOL ELECTRIC �UrcH11NG
GOTHER
p. will Jo Ne work,and the saucmre is not intended Oroffcad for sale(See.]IW,Business t1
W
3 ao and Proa
fessinns Code:The Contmor'License law Jens nm apply m ua Owner of OUTLETS-SWITCHES-FIXTURES q 1 IJ
Propcny who hails or improves Nemon,and who does.such work himself or through NIiW RESTDENTIAI,ELECI'R SQ ITT his s wn employem
s,pvidcl that such impmvenscnts art not intended or offered for S4�FLJI t;(IR��t ® VSO.FL
sale.If.however the building or improvement is sold within one yearn!completion.the
a QCI 1u R[
erboilder will have the borJen of proving that he did not build nr improve for par- 0
poen of wlcJ. 'ft 1 1
h os Owner of the prepcny,am exclusively contracting with IimnwJ contractors m ur�H f IND
omwm the project(See 7044.Business sod profcasionz Code:)The Cnmmcmrx Li C' O
move Law does sO apply to an owner of property who builds or improvc.dwaron.had QTY. PLUMBING PERMIT FEE
whocontmcu for such pmjccrc with a conmctur(M IianwJ pu sushi m Nc COmmnnrs ZZ
Lietre �r/ //son PERMIT ISSUANCE ✓J
01. '� i! Mt46n
AI:I'IiR-DRAIN.Pr VENT-WAIT:R ILA) VALUATION
Owner Data
O KERS COMPEN.A ION DECLARATIO BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of Ne follmving declarations:
❑I hvweand will maintain a Certificate of Comentto w161nsure for Worker's Compcm DRAINS-FLUOR.ROOF.AREA.COND. - S1ORII!S TYPE CONSTRUCT HH'
Orion.a%provided for by Section 3710 of the labor Cods,for the performance of the
walk for which this paten is issued. FIXTURES-I'IiR TRAP
FI 1 have and will maintain Workers Compensation Insurance,as required by Section
3700 Offal labor Code.for the performance oftbe work for which Nis Permit is issued. GAS-IEA.SYS1 EM-1 INC J OUTLET'S OCC.GROUT' APN
My Workers Compensation Insurance carrier and Policy number art: GAS-IEA.SYSTEM-OVER J(BA)
Carrier. Policy No.:
CERTIFICATE OF EXEMP71ON FROM WORKERS' C.REASUYINDUSTRL WASTT INE.RCF.PIT)R
COMPENSATION INSURANCE BL DIVISION PEES
(Thiswetionneed nmbecompletedifthepenat is faros,hunNeJdollars141(X) GREASBTRAP
I'hANCIIIiCK PF
or les.)
I certify thn in the pcdormance of Nc work for w hich this permit is issued.l shall SEWER-SANITARY-ST ORM EA.2100 IT.
not employ any Flood in any alliance so as m become wbjecrao the Workers'Counpcn- ENERGY FEE 00"',z cation Laws of California.Date WA'ITR H17AI'HR WIVENT/ELECl'R GRADING PEE
ZO Applicant
NOTICE TO APPLICANT:If,vftx,making this Ccnificam Of Esemlvinn,you should WATER SYSTEMITREATING 5011-SFEE
CZ becnmcaubjectto the Worker's Compensation provisions of the Labor Code.you must
forthwith comply with such provisions or this pennitshall he deemed revoked. WATER SERVICE
PAID
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL('LMB. SQ�FT, Dam Rwcipt p
U (hereby affirm that there isa conwuction lending agency for the performance of
— the work for which this permit is issued(See.3097.Civ.C.) TOTALi
O Lender's Nume Of L.
[U Lender's Address BUILDING FEE?
I cenify Ort 1 have read this application and state that the above information is
N correct.l agree to comply with all city and county ordinances and state lawn relatingto QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U z building construction.and hereby authorize reprewntatives of this city to enter upon the
abrrvcmemioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC Flit?
(We)agree m save,indemnify and keep harmless the City of Cupertino against
Iiabilitie',judgments,costs
�{p'and expenses wyhhich may in any wayaccoun agaml,said City AI.TIiROk ADD'IOMIiCH. PLUMBING FIiE
a.catiol iiente of he got
SAPPI DP TT UNDERS(/sNDS NO L C�f I nLYJYqM)l T AIR HANDLING UNI'1'(TD 1fimc C17M) MGCHANICALITi
}n/^ia C /, I/d�1 Nj a� AIR HANDLING UNIT(OVER 1000)CPM) CONS'I'RUCI]ON TAX
Sign p lecavc.am ctor )5{R,�„L EXHAUST 11001)1W/DUCT) HOGSING MITIGATION FEE
HAZARDOUS MATF.RIAIS DISCLOSURE.
Will the applienntnrfumm M1uilJing owcnryim summ,r M1unJle bourdnoanou,nA HEA'T'ING UNIT(10100ml It U)
as Joined by the Cupertino Municipal Cmlc,Chapter 9.12,and the health and Safety I IITAI INC,UNIT(OVER I ANN)BIT)
Code,Section 25532(a)?
0 Yea F7 No VFN1'ILAI'[ON PAN(SINGLE RIMD) PAID
Uuw HccviplN
Will the applicant or future huilding occupant use equipment or devices which BOILER-COMP(9111.OR Im%oX)It I U)
emit hazardous air ammmimmns as defiled by the Bay Are.Air Quality Mi nagcmetn 'IffIAL'
Dania? EGIhI1H-CUMI'f11V1?R IfNI,(llN)ITIL)
i
El Y-1 0N
nIH COND I'I'IONIiR ISSUANCE DATE
I have mad the hur.de,le materials 5,1111 Ona under ,1 no r 6 9sour 0l the Call-
Ibmia Ilcuhb m t cumy Code,e a encs,that i 25tH}and tuldad I r0 1 vsnnh Nm If the NI?W RI?SIUI?N'IIAI.MliCll. 9Q.PT.
builJingJx'nol curenOy lnrven wnunl that it in my vpanaibil'nymnrnity the Oenpmn
of,he n.gwrcnters which Inaam be Inn prier In i'xn r ce of a Ceniliaau of Occupancy.
Owner or authorized agent Dutc 'I )IA ISSl11iU RY:
OFFICE